This week’s post is different from our usual. No exploration of health disparities, no risk-reducing tips. And no complicated studies. Instead, this week I wanted to take a moment and explore the bisexual vs pansexual definition debate.

I will admit that like most posts, this one was inspired by an article. But this was an exploratory article looking at the definitions of pansexual that were online, not a formal study that recruited participants. I’m not going to explore their published results here. Instead, let’s talk definitions.

Why does language matter? Why talk about this?

The purpose of language is to communicate. To communicate, we need a common set of ideas we all agree on. If I say that “That tree is red”, you and I would need to share concepts for me to be understood. If your concept of a tree is a bush and my concept is a giant redwood tree, I would have failed to communicate. The same is true if my red is orange and your red is purple. My sentence would not be understood in the way I intended it.

Language also matters in terms of identity and labels. We use words to self-identify. We intentionally put ourselves into boxes. By doing so, we can use labels to quickly communicate. We also claim an “us” group we belong to. We claim a tribe, one that gives us a psychological sense of wellbeing.

In addition, language can hurt. That hurt may or may not have been intentional. The connotations, or unstated associations, of words have as much impact as the words themselves.

So there are several reasons to talk about language and word choice.

What is bisexuality?

The bisexual flag

Bisexual is an older term than pansexual. Bisexuality was originally used to refer to plants with both male and female reproductive parts. The definition changed in 1892. Bisexual referred to humans who had sex with both male and female partners that year. By the 1970’s, groups of bisexuals joined with homophile (gay and lesbian) groups. They advocated for equal treatment and raise awareness.

Modern definitions of bisexual include:

a person who is romantically or sexually attracted to both men and women, or to people of various gender identities; ambisexual. [Dictionary.com]

of, relating to, or characterized by sexual or romantic attraction to members of both sexes; also: engaging in sexual activity with partners of more than one gender [Merriam-Webster]

What is pansexuality?

The pansexual flag

Pansexual is a much newer term. Sigmund Freud coined the term in 1926. Yes, that’s the “father” of psychology. He used the term to refer to sexual energy drives all human activity. Modern usage of the term seems to have emerged in the 1990’s. In particular, it became popular when Miley Cyrus came out as pansexual.

Today, the definition of pansexual includes:

of, relating to, or characterized by sexual desire or attraction that is not limited to people of a particular gender identity or sexual orientation [Merriam-Webster]

expressing or involving sexuality in all its forms, or sexual activity with people of any sexual orientation or gender identity. [Dictionary.com]

Some pansexuals also include gender-blindness in their definitions. Others explicitly include attraction to intersex and trans people in their definitions.

What’s the difference? They seem awfully alike…

And, in truth, there’s a lot of overlap. Both bisexuals and pansexuals are attracted to more than one sex or gender.

Bisexual is an older, more well established term. That also means it carries certain stigma. You likely know the stereotypes already — that bisexual people are promiscuous or can’t make up their minds. There’s discrimination from both the straight and gay communities.

Pansexual is new enough that it isn’t nearly as widely known. Ask an average person on the street and chances are they won’t know what it means. Pansexuals also face the stereotypes of promiscuity and inability to make up their minds.

What I’ve heard pansexuals say is that pansexuality emphasizes acceptance of genders and sexes outside the binary. That is, genders other than man/woman and sexes other than male/female. Some pansexuals explicit include attraction

The politics

And here is where the politics come in. Because of course there are politics.

Some bisexual people feel that term pansexual is an attempt to express the same sexual orientation as bisexual, only without the baggage of the term bisexual. Others argue that the pan in pansexual implies hypersexuality. Pan means “all”. Does that also mean attraction to all humans of consenting age? What are the borders of pan?

In turn, some pansexuals argue that the term bisexual refer to attraction only to two cisgender sexes. They say that bisexuals are not attracted to androgynous, transgender, and intersex people. Except that many people who identify as bisexual are attracted to those people. Those bisexuals resent being put into a box that implies transphobia.

Other pansexuals say they are attracted to “the person, not their parts.” Does that imply that bisexuals are attracted to the parts more than the person?

Yet others have argued that bisexual is an umbrella term that includes pansexual. In this scenario, bisexual might refer to anything other than straight/gay. And pansexual might specifically refer to attraction to all genders/sexes. Another term, as yet undefined, lumped within bisexual might then refer to someone who’s only attracted to a subset of genders/sexes.

But as you can see, there are a lot of minefields in this debate.

That’s…complicated

Yes. Yes it is. If you’ve made it this far, congratulations. Debate over definitions can be confusing. I’m glad you’re still with me here.

I’d like to leave you with my personal thoughts.

Here is how I personally define and use bisexual and pansexual:

A bisexual person is attracted to more than one sex or gender. I used it as an umbrella term, including anyone who isn’t heterosexual/straight or homosexual/gay.

A pansexual person is someone in a subgroup of individuals within the bisexual group. In general the term refers to people who wish to explicitly welcome gender nonconformity and non-binary gender identities.

I tend to use the terms roughly synonymously.

Because of its age and flexibility, I prefer the term bisexual. It’s the one that I choose to use for myself. It’s also the term I default to when referring to people who are not straight or gay.

However, I don’t personally identify with the term pansexual. So I try to get my definition from those who do. I also try to avoid labeling other people with labels they themselves do not use. If someone prefers bisexual, I’ll use that. If someone prefers pansexual, I’ll use that.

Remember: Language needs to communicate. I try to communicate to as many people as I can. So I tend to default to terms that are commonly understood. It has the best chance of communicating. I use the same philosophy when it comes to bisexual and pansexual.

Although languages need to communicate, they also evolve to meet the needs of the speakers. The definitions of bisexual and pansexual are likely to change. I look forward to seeing it.

All lesbian, gay, and bisexual (LGB)* people are not the same. I’ve long been an advocate that it’s not “the LGB community”, it’s “the LGB communities“. Even within just the lesbian “community”, there are subgroups. Everyone has different experiences, needs, and expectations. There is no one universal experience, and no monolithic community.

The easiest example is gender nonconformity. Within lesbian and female bisexual communities, for example, there are women who dress and act more masculine (“butch”) and women who dress and act more feminine (“femme”). The same is true for gay and male bisexual communities. Another example is “coming out”. While it’s a common experience, it’s not universal. I myself never had to “come out” to my family because my family was very accepting.. Bisexual people who date/marry opposite sex partners may also not choose to come out.

Despite differences, we know that there are some generalities about LGB communities. We know that LGB people, as a whole, have higher rates of depression than their straight peers. But we also know that not all LGB people have depression. Could gender nonconformity be the key?

Portrait of a boy, c. 1800. A boy who looked like this might well end up with depression after being teased and bullied.

Today’s study looked at depression, gender nonconformity, and LGB status among young adults in the United States. They used data from the Add Health study. Add Health was a study that started in schools and continued through until the participants were up to 32. The participants in today’s study were age 18-32. 86.7-93.1% of the sample (women-men range) were heterosexual. The rest were mostly heterosexual, bisexual, mostly lesbian/gay, or lesbian/gay. Depression was measured with a validated scale. Sexual orientation was rated on a Kinsey-type scale. And gender non-conformity was measured with a scale of activities, including team sports, religious activities, video game use, housework, and social activities.

What were the results?

At first, it looked like all the non-heterosexual participants were at higher risk for depression. Bisexuals had more depressive symptoms than lesbian and gay participants. However once they controlled for gender nonconformity, lesbians and gay men did not have more depression symptoms than heterosexuals. Bisexual participants continued to have higher rates of depression and controlling for gender nonconformity.

Who tended to be gender nonconforming? Young men were more nonconforming than young women. Lesbians and gay men were more nonconforming than all the bisexuals (including mostly straight and mostly gay), who were about as nonconforming as straight participants.

And the depression? Young women were more depressed than men. Black, Latino, and Asian participants were also more likely to have it. The same was true for those with low parental education levels and families with financial problems. Participants who were gender nonconforming reported more symptoms of depression than those who were conforming.

Lastly, the researchers looked at whether that depression held over time. Gender nonconformity did not predict depression in the future. Bisexuals, lesbian, and gay young adults were also not at risk for future depression; only depression in the moment. However individuals who identified as mostly heterosexual continued to have higher rates of symptoms. Individuals who are Black, Asian, female, had low parental education levels, or severe family financial problems, continued to have depression symptoms.

What does this really mean?

LGB young adults as a whole continue to be at higher risk for depression. However, that risk appears to mostly be an effect of gender nonconformity as a young adult. Those who are gender nonconforming as young adults are at higher risk for depression as young adults, but six years later that risk goes away. Why? Gender nonconformity is visible, and likely to result in the individual being a target for discrimination, which can result in depression. But then why doesn’t it continue six years later? Either the discrimination reduces (teenagers can be notoriously mean to each other), or the individuals develop coping skills or move into a more accepting community.

Additionally, bisexuals and mostly heterosexuals are at higher risk for depression than lesbians and gay men. Why? Well, it might be because they can “hide” and look heterosexual. That means they don’t need to “come out”. But it also means there’s less acceptance and acknowledgement of their orientation. That could have big effects.

What do we do with this information?

First, we can keep an eye out for the gender nonconforming young adults in our communities, whether they’re straight, bisexual, gay, or somewhere in between. We can support them when they need it. And second, we can create a more accepting environment. The less discrimination and the more acceptance of gender nonconformity, the less depression we are likely to see. We can make the world a positive place to be for everyone.

*: Please note that although today’s article does not use the word “cis” throughout despite the implication. The study in question examined cis individuals. However in my language, I use “men/male” and “women/female” to refer to gender identity, not biologic sex. So the general statements I make are intended to be inclusive of both cis and trans individuals, who can be lesbian/gay, bisexual, or straight.

There are a lot of unknowns when it comes to hormone therapy for trans people. Which androgen is best for trans men? Are there long-term risks if they don’t have their ovaries or testes removed? And can we develop a way to give trans men testosterone that doesn’t involve needles or creams? This week’s paper tried to answer one question: What happens to trans men’s uteruses with all that testosterone?

Loverro et al recruited 12 trans men in Italy to participate. After examinations making sure they didn’t have any lurking cancers that might flourish with extra testosterone, they received intramuscular testosterone therapy. On average they were on testosterone for 32 months (roughly 2.5 years) before going on to have hysterectomy/oophorectomy. The uterus and ovaries wer then examined under the microscope. Estrogen and testosterone levels were also tracked throughout the study and up to one year after surgery.

What did they find?

First — a caveat. I’m not going to present all the nitty gritty details of the results. I don’t think the percent of Ki-67 receptors found in each tissue type is useful for most people. Nor do I think the details of exactly what their hormone levels were was useful. (They were in the therapeutic ranges). So I’m keeping my analysis here at the ten thousand foot view.

Loverro et al found that the uteruses did not atrophy with testosterone. The uteruses continued to be in an active state. Several trans men had a secretory uterus. That means their uteruses were building up the lining. In cis women that’s during the phase just before ovulation (when the egg is released). In trans men who don’t menstruate it’s harder to tell what’s going on. They also found that the muscular layer in the uterus was bigger, just like all muscles get bigger with testosterone.

When they examined the ovaries, they found that most of them were large with multiple follicles. The larger size was mostly from more connective tissue (collagen). That means more stuff in between the hormone producing cells, not more hormone producing cells. Multiple follicles were also found, just like in polycystic ovarian syndrome. That is a known effect of testosterone. And just like in PCOS, the larger follicles probably caused fewer menses. All of these ovarian changes were likely an effect of the testosterone.

That’s nice and all. But what does it mean?

It’s important to know that the uterus does not atrophy. That means trans men are still at risk for endometrial and uterine cancers. We don’t have any long term information on whether trans men are at high, low, or average risk for those cancers. However trans men should definitely seek medical advice if they experience spotting, cramping, or unexplained weight loss. As always, they should follow up with a primary care provider, like a family medicine, internal medicine, or ob/gyn doctor.

Medical transition for trans people has only been available in the United States since the 1970’s. Because it’s so new we only have limited data about long term risks and benefits. When I was first learning about trans health I was frustrated by the lack of data. Are trans women protected from heart attacks like cis women are? Do trans men have lower risk for osteoporosis like their cis men peers do? We simply don’t know.

Today’s study is an exploration of the long term morbidity and mortality of trans people who have had surgery. Morbidity and mortality are just fancy words. Morbidity refers to disease or suffering. For example, morbidity may refer to how many people had a heart attack but are alive. Or how many people live with depression, or low back pain. Mortality is how many people died.

Who did they study?

Simonsen et al took advantage of the Denmark health system. In Denmark, there is one national health system. So they were able to look up how many trans people there are in Denmark. They were then able to figure out who had had gender-related surgery. Using medical billing codes, they looked at the diseases and disorders those trans people were diagnosed with. And they used death certificates to determine cause of death. They looked at records from 1970 to April 2014.

In total Simonsen et al looked at the records of 104 trans people. 56 were trans women and 48 were trans men. Surgery was performed between 1978 and 2010. So the patients with the most recent surgery would have been 4 years post surgery.

Most trans women (65%) started hormones age 22-42 and had surgery 9-23 years before the study. Trans men started at similar ages, 21-38 and had surgery 4-1

Beech trees in Denmark, where this study of morbidity and mortality was done

6 years before the study.

Their findings

In total, 20 trans people (19%) were diagnosed with a disease/disorder before surgery. That increased to 24 after surgery (23.2%). However, the difference wasn’t statistically significant. That means the difference was likely because of chance.

Diseases seen in this study included cancer, cardiovascular disease, musculoskeletal disease, chronic lung disease, and alcoholic liver disease. Almost all of the diseases were related to behavior and not to hormone therapy or the surgery.

Cardiovascular disease was seen in 10.7% of trans women and 25% of trans men. Compare that to 3.5% of cis women and 4.4% of cis men. The high rate of cardiovascular disease is likely a result of smoking, since high rates of chronic lung disease were also soon. Chronic lung disease includes COPD, which is usually caused by smoking tobacco. Chronic lung disease was seen in 3.8% of trans people. In comparison, 1.3% of cis people had chronic lung disease. There was no difference between before and after surgery in either cardiovascular disease or lung disease.

In contrast, there was a difference seen with alcohol. Alcohol-related diseases were seen in 3.8 of trans people before surgery. After surgery that number dropped to zero.

Musculoskeletal disease was unique. It was found in 10.5% of trans people, compared to 13.9% of the general cis population. So musculoskeletal disease was the only one that trans people, as a population, had less of.

Cancer rates were also higher in trans people. 6.2% of trans men and 3.6% of trans women were diagnosed with cancer. The general population rates are 1.6% of cis men and 2.4% of cis women. The cancer rates seem to be because of increased risk of lung cancer from smoking, however Simonsen et al did not publish the details.

What about deaths?

10 trans people had died in Denmark between 1970 and 2014. That’s 9.4% of all the trans people in Denmark. The average age of death was 53.5 years. The average age of death for the general population in Denmark is 81.9 years for women and 78 years for men. The causes of death were mostly from smoking and alcohol abuse. However, two trans people committed suicide. One was 19 years after surgery, the other was 26 years after surgery.

What do these results mean?

First, that gender-related surgery for trans people does not increase the risk for medical disease. There was no change in disease before and after surgery.

Second, rates of cardiovascular disease, lung disease, cancer, and alcohol-related disease are higher in trans people than in cis people. Smoking tobacco and alcohol seem to be the cause, not hormones. And smoking and alcohol are likely because of stress from discrimination and gender dysphoria.

Third, the average life expectancy for trans people in Denmark is much lower than the general life expectancy. Again, this is because of smoking, alcohol, and suicide.

What are the caveats?

This was a tiny sample. While 104 trans people is a large sample for trans research, it’s a small sample to try to draw large conclusions from. Worse, some of the sub groups were miniscule. It’s near impossible to draw accurate conclusions from only 4 people with lung disease, or 2 suicides.

I was also surprised at the lack of HIV-related diagnoses in this study. HIV is prevalent in trans women in the US for complex reasons. Is the rate lower in Denmark? I don’t know.

And as always, this was one study in one country. Every culture and country is different, with different levels of discrimination and different cultural standards. So we can’t make assumptions about other cultures based on this one study.

Despite the limitation, this is an excellent exploratory study. We should continue to look for more data coming out of Denmark to see what more we can learn.

The term intersex is synonymous with differences/disorders of sexual development (DSD). We are taught in grade school that men have XY chromosomes and have a penis and testicles. Women are XX and have a vagina and uterus. And some go so far as to claim that those two sexes are the only human sexes. Well, they’re wrong. People with DSDs or who are intersex are those whose biological sex is different in some way.

Obviously, human embryology is complicated. But here’s a simplified summary. As embryos we’re all the same. Our gonads are the same blobs of tissue. The genital tubercle, a lump of tissue with a fancy name, can become either a penis or a clitoris. With testosterone and working testosterone receptors, the tubercle grows and becomes a penis. Likewise, the gonads become testicles. Without testosterone and working receptors, those structures become a clitoris and ovaries.

What are intersex medical conditions?

A roman fresco of Pan and Hermaphroditus, found in Pompeii. Hermaphroditus was the origin for the term “hermaphrodite”, which is an old and no longer used medical term for intersex/DSD individuals

Here are two examples of intersex/DSD medical conditions.

An individual can have XY chromosomes, have testosterone, but have testosterone receptors that don’t work. Without working receptors, their body develops along the “female” path. They have a vulva, vagina, and clitoris. They also have testicles inside. This is called Androgen Insensitivity Syndrome (AIS).

AIS can be “complete”, where the receptors don’t work at all. Or it can be “incomplete” where the receptors work a little, and the person has a more mixed biological picture. Individuals with AIS often present and think of themselves as female. They may not even know they have AIS until they don’t have periods or try to get pregnant.

On the other hand, an individual can have XX chromosomes and have hyper-active adrenal glands. The adrenal glands sit on top of the kidneys and produce a lot of different hormones. That includes some sex hormones. So hyperactive adrenal glands means more testosterone. More testosterone means that genital tubercle becomes a penis and the labia become a scrotum. So the individual has a penis and scrotum, but has ovaries hidden inside. This is called Congenital Adrenal Hyperplasia (CAH).

Like AIS, CAH can be more “complete” with a fully developed penis and scrotum. CAH can also be “incomplete” with a mixed picture. Individuals with CAH often identify as female. Some do identify as male. Some forms of CAH are potentially fatal, since the adrenals also make hormones that change how salt is handled by the body. Individuals with that form of CAH, called “salt wasting”, need to take steroids lifelong. Today, we test infants for CAH at birth.

Other forms of intersex exist. However those are the two discussed in the paper. If you’re not familiar or comfortable with intersex terminology, it’s probably a fair place to start.

So what about this week’s paper?

This week is a paper published by Beale et al. They examined long term health outcomes in intersex individuals. Their paper summarizes the published research.

We don’t have a lot of data on long term health outcomes in intersex individuals. Physicians used to advocate for early surgery for infants and a gender assignment. Physicians feared that children would be confused if they knew they were intersex. So they recommended that the person not be told they were intersex. Then intersex adults spoke up.

Surgery for infants is no longer standard. Effective treatment of intersex children really only started in the 1960’s. It didn’t become patient-centered until much later. So we don’t have many older intersex people to study or listen to. But we are starting to collect data. Let’s look at what we have.

Congenital Adrenal Hyperplasia

People with CAH need to be on steroids life-long. The steroids keep the adrenal glands quiet. Without steroids, the adrenals go back to producing lots of testosterone. The person may become masculinized. And for some patients, the adrenals may produce too much of the hormones that balance salts and water. That is life-threatening. Consistent visits with a health care provider throughout their lifetime is important.

But we also know that steroids have their risks. Osteoporosis is one risk. So far, individuals with CAH do not appear to be at higher risk for osteoporosis. The other known risks for people with CAH are obesity, high blood pressure, and abnormal lipids (including high cholesterol). So far we don’t yet know if there’s a clinical impact yet. That is, we don’t know if people with CAH are at higher risk for heart attacks or strokes. Studies will continue to follow people with CAH to find out.

Individuals with CAH are able to get pregnant as long as they have a uterus. They do need higher doses of steroids during their pregnancy. Additionally, they may need psychological support through their lifetime. But their quality of life is similar to that of people with other adrenal conditions.

Androgen Insensitivity Syndrome

AIS does not have a long term need for medications like CAH does. However, there are risks associated with having testicles inside the human abdomen. Testicles like to be kept cool. That’s why they migrate to the scrotum. Individuals with AIS are infertile because of the warmth of the abdomen. And testicles that stay in the abdomen have a risk of developing cancer. For that reason, we advise people with AIS to have their gonads surgically removed.

Some people with AIS may choose to keep their gonads until they go through puberty. The testosterone that’s produced by the testicles gets converted to estrogen in their bodies. So they can have puberty without taking hormones. Keeping the gonads that long is a risk, though. People with AIS need to talk with a knowledgeable physician about gonad removal.

For people with AIS who have had their gonads removed, starting hormone replacement therapy is crucial. Sex hormones are needed for healthy bones. If they have a uterus they should receive both estrogen and progesterone. The progesterone protects the uterus from developing cancer. If they don’t have a uterus, they can take just estrogen. Remember – their testosterone receptors don’t work, so giving testosterone won’t help. Individuals with AIS can become pregnant through egg/sperm donation if they have a uterus. Otherwise they will need to adopt or use a surrogate.

Just as with CAH, psychological support for people with AIS may be crucial. AIS can also be diagnosed later in life than CAH, so making sure the patient knows their diagnosis and is supported during that time is important.

Conclusion

As with LGBT health, we just don’t know a lot about the long term health of people with intersex conditions. Long term risks of cancers like breast cancer, cardiovascular disease, and other diseases/disorders are unknown. Stay tuned, and I’ll continue to cover studies as they’re published.

What can you do with this information?

First — if you are an intersex individual or have been diagnosed with a DSD, I recommend joining a study. We need data. Second — find a doctor who treats you well. Keep them in the loop. See them regularly. Ask them questions. If you need to change doctors, make sure you have all your records. Third — take care of yourself. Eat well. Exercise Take your medications. Avoid or reduce drug use. And remember to breathe and enjoy life.

What is Open Minded Health?

OMH is dedicated to providing information about gender and sexual minority health. Posts are a mix of the latest research, activity risk reduction tips, and the latest news.

This blog is definitely not suitable for children, and probably not work safe. It contains descriptions of sexual activities that may disturb some readers.

Also please be aware: I am not a doctor. OMH does not provide health care advice - the information here is to be used as information only. It does not substitute a visit to your health care provider. When in doubt, please ask your health care provider.

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